Episode Transcript
[00:00:03] Speaker A: Welcome to the Ortho Joe Podcast, a joint production of the Journal of Bone and Joint Surgery and Ortho Evidence.
Join hosts Mohit Bhandari and Mark Swankowski as they discuss current topics and publications in the world of orthopedics and beyond.
Well, good morning, Mo.
[00:00:20] Speaker B: Good morning.
[00:00:22] Speaker A: It's very early up here in the lake region of Minnesota and I have the again the, the famous Northern pike cup available. I know you haven't been to Tim Hortons yet and you're a little bit not as sharp as you normally would be.
And I hope that can be rectified soon with, I don't know, does Tim Hortons deliver to your house?
[00:00:44] Speaker B: There is an Ubereats, but I can tell you it is an embarrassing thing to have an Uber bring you a $40 cup of coffee.
[00:00:51] Speaker A: So yeah, that's true. Which is probably not hot anymore.
[00:00:54] Speaker B: No.
[00:00:56] Speaker A: And we, we've got our esteemed colleague that we have traveled to international meetings many times with. Dr. Brad Petrasor from your institution of McMaster.
[00:01:07] Speaker B: That's correct.
[00:01:08] Speaker A: Professor of orthopedic surgery and photographer and videographer extraordinaire, the Bandari team.
And what I thought would be a great topic to discuss since I'm headed off to the American Board of Orthopedic Surgery oral boards next week, is just how orthopedic surgeons worldwide, and I know you both have got substantial experience.
How is the public assured that orthopedic surgeons are competent to manage their career?
For starters, let me just explain the United States way we do things. So immediately after a resident completes their training, five years before their fellowship year, they do a written boards, which is very expertly done and a lot of money spent on psychometrics, et cetera, making sure that the items are discriminative, et cetera, et cetera. And the pass rate fluctuates.
Usually there's 7, 800 kind of people taking the exam, ballpark numbers. So the pass rates kind of function fluctuate between high 80s and low 90% pass rate. And individuals can retake the exam. And once they've passed the exam and they've practiced in a location that the numbers have changed a little bit. I think it's 16 months now. I may be wrong, but that's not the major issue.
Then they submit a case list, a six month case list to the board and then 12 cases are selected for them to be examined on.
And they're examined with four pairs of two examiners who assess the quality of their care, their ethics, their professionalism, their skill, their management of complications, et cetera. And every one of those eight examiners is blinded to what the other seven are scoring. And then they're graded on a 01230 meaning terrible and three being outstanding. And if the individual has a fair average of 2, which is basically adequate care, then they pass the exam.
And so I'm headed off to the oral boards which are at the Palmer House in Chicago generally in July.
And I've been doing that for over 20 years. And it's a very robust and fair exam and that's, that's the way it's done in the United States. So Brad, let me just ask you, you're an experienced examiner in Canada. How is it done in Canada?
[00:03:45] Speaker C: So in, in Canada, similar length of time you need to sit and, and, and study and work in a five year training program. So you need 60 months of training before.
And everybody writes one single exam put forward by the Royal College of Physicians and Surgeons in Canada.
And there are two parts to the exam. The Royal College has moved the timing a little bit, but essentially there's a written component which is, you know, a day or a two day written multiple choice question component that studies and people study, you know, train to about knowledge and all that sort of stuff. And then subsequently once you are successful in that, you go to the practical component which is an osceola. So it's similar to yours, but they're not their own cases. There's an osce examination whereby they go through multiple stations. Each examiner doesn't know what the other people are examining and will examine an oral component and practical component of orthopedics. And sometimes the Royal College will bring in standardized patients whereby you can have, actually have assessed for communication and all that sort of stuff. And oftentimes most of the time I would say it assesses a clinical algorithmic approach to care. And so then those two marks are combined and then you get your ultimate pass.
It's similar to the way you're describing it. There's a fairly, there's really consistent biometrics and marking in the way the exam is scored and that sort of thing.
This approach and similar to, I believe your approach, one singular examination makes it exceedingly consistent what people are learning throughout their five years. And everybody's thinking, okay, well this is, you know, this is where we're headed. We all maintain a focus day to day, but everybody has this overarching, here's what the, you know, the exam at the end and here are the things that I need to know for that exam. So you Know, there are, you know, roughly 17 orthopedic training programs in Canada, all writing the same singular examination. It makes for very, very consistent training. And the nice thing is the examiners get together a couple of days beforehand and go through all of the questions. So not only, not only do we see what people are examining on where we have a consistent approach to the way, what we're going to accept as answers for the exam.
And so it's, it's really, I think, really well done in that way. Kind of similar to your system whereby it's just consistent and it makes for consistent quality of orthopedic surgeon.
[00:06:32] Speaker A: Let me just. Brad, do you have a sense of the pass rate?
[00:06:36] Speaker C: I do.
It's 90 over 90%, usually very consistently.
[00:06:43] Speaker B: Yeah, yeah.
[00:06:44] Speaker A: Go ahead, Mo.
[00:06:45] Speaker B: So for someone who's not day to day involved in the examination process, let's take an alternative view. You'd say you could say if you had a skeptical view and say, so how? You're telling me you can give someone a bunch of questions, written exam, multiple choice or other, and then you can ask them on a few cases, we'll say few relative to the, you know, the multitude of cases that you would expect that they would have to know. And you're telling me you can determine that they're going to be, you know, careful and competent and they're going to be excellent, you know.
[00:07:14] Speaker C: Yeah, I see where you're going with that question.
And how can an exam determine competence? The Royal College, at least in Canada, puts all of the onus on the programs and the programs will not send a candidate to the test at the exam if they feel that they're not ready surgically. So the programs determine the competence. And that's been the big move by the Royal College to move to a competency based education system whereby you obtain your competence, whether in five years and you're not put forward to the exam until you're competent, until you're ready. And there are people who are held back here to do more.
So that's, that's the general approach.
[00:08:05] Speaker A: And it's the same in the US an individual can't sit for the written exam until the program director and the chairman of the department have signed off on their clinical competence. But Mo, I know you've got experience in Hong Kong as well. You've served as an examiner.
[00:08:20] Speaker B: Yeah.
[00:08:21] Speaker A: How is that done in Hong Kong?
[00:08:23] Speaker B: I mean, I mean, you would think, and I imagine this is in many ways the way it was done in the past in other parts of the world. But I think they're governed through the Royal College of Physician Surgeons of.
Is it Edinburgh? I believe that that's what it is. And so what will happen is, is that really pretty well, pretty similar to everything else you both have said with the addition of. And this is what for me was a little bit, you know, it was, you know, it was pretty pressure packed, was, you know, live patients. It wasn't patient scenarios, Brad. Like, you know, it was individuals who were, who were brought in, who are, who have, who have a particular symptom pathology and you know, they were given 10 minutes to evaluate, ask questions and then have answers. And so that was a different part. And I imagine the big challenge and the barrier of that is just, you know, volume. How do you do that? There, there's about 40 trainees or 40, 40 to 45 or so that will be examining so they can manage it. But I can't imagine that for, you know, hundreds of trainees, just the amount of cost, energy and organization it would take. So I think that's a bit of a priviting factor.
The other thing I will say, and it wasn't, this is not hyperbole, it was like you could go into a question answer period. You know, we know Brad, we used to always hear Mark, you know, they, that well, pathway you give, any pathway you give, you will be asked, you can go any possible way you want. And that was also interesting. There was standardization quite a bit but really you could go in any direction you wanted. And it was a sense of saying, how do we get a sense of this individual?
On the positive side, I will say, and I think you've all experienced this, it is pretty remarkable how after about 10 minutes of talking to somebody you can get a general sense about, you know, how they see, you know, sort of the management of patients, how they're likely to interact with patients and their general approach, whether it's systematic or haphazard. So I do, I do feel that there is quite a bit, somewhat amazingly that you can determine the assessment of competence pretty quickly.
[00:10:31] Speaker A: And I'm sure there's many more variations on the same theme in other countries. I don't know that much at all about the UK system, for example, but it's probably similar in all aspects. And I do know enough about this whole process that the whole world is trying to consider safe ways to move from time based training to competency based training. All kinds of efforts being put in by the American Board of Orthopedic Surgery in trying to figure out how to do that. Because we've all been around trainees that are ready for practice after three and a half years, have amazing skills. They're just, they're exceptional, unusual people. So there's that movement. But really I think one thing that's underemphasized, I would say, I would hazard guess worldwide is the, the role of the community, the local community of surgeons in policing our own.
Because we've been in situations, I certainly have. And I would hazard a guess that both of you has as well. In your community there may be people who really literally are not competent and it is a very, very emotionally and time and potentially legally expensive way to get involved in trying to help individuals get additional fellowships etc or you know, come and scrub with me or potentially going with the, the overseeing environment in the province or the state to have them look after license. That is a very, very expensive procedure in many, many ways. But essential, you know, I think ethically essential that if there are people in our community that are harming patients, we really need to just buck up and get involved. Very difficult. Yeah, very difficult.
[00:12:32] Speaker C: That's a really hard situation.
And then we've all seen aspects of it. And what makes it hard I think is twofold. One, you're right, we have as a self regulating profession have a ethical duty to regulate ourselves essentially. But there's also this, this concept of, you know, throwing stones in glass houses. Right?
[00:12:57] Speaker B: Yeah, yeah.
[00:12:57] Speaker C: You know, we all have complications. We get, we get. And, but does that correlate with doing surgery that may fall under par slightly and, and we have to equate those two. And then the other piece to that puzzle is, you know, how do we capture every single case? Often the cases are curated that you're going to judge people on and then you may not see everything bad, that's not as good, but you also don't see things that may be great. So it's very nuanced though. And when you're dealing with someone's livelihood, it's hard but you're also dealing with patients livelihoods. So you're right, it's really a nuanced situation.
[00:13:44] Speaker A: Yeah.
[00:13:45] Speaker B: So Mark and Brad, a bit more of a provocative question for someone who, who let's say you said, you know, that is clear, individual is clear that they're having difficulty in practice and you know, their care may be outside normal standards of care.
How far back do you go? I mean like, you know, could you have, could you make an argument that the residency training that individuals would have known about this person would they have, you know, and what, what can we do as early as possible to flag and be careful rather than say, let's just, okay, eventually they'll figure it out. Okay, they're, they're good enough. Move them on, move them on, move them on. You know, where does that responsibility ultimately end up?
[00:14:23] Speaker A: Well, I think you've hit on a very, very important. And the essential concept is it's, it's on the training program and to counsel and work with an individual who is just not going to make it is a very, very difficult thing. But it's effort, involvement of all the faculty at all the training sites to try to work with an individual, give them additional motor skills opportunities.
Usually these things are on the technical side. It's not on the, on the ethical side, it's, it's individuals really trying to get better, but they need extra help. And it's a lot easier to just pass them on to the next year than it is to engage in an intensive assistance program to bring them up to standards.
[00:15:12] Speaker C: Yeah, it's, it's really interesting too. And I, I do think it's a bit nuanced and I, I see these situations in the early trainee, as you've said, mo, But I also see it potentially in the later years, trainee or surgeon that maybe hasn't kept up or isn't aware of some of the techniques or maybe is using a little less fluoro in the OR and that sort of thing.
But each of these, I think, brings forward how important it is to have a supportive group environment.
Because I have seen trainees graduate and go do locums and basically just no one supports them. They go and they don't have anybody to talk to and be. And it's the same with someone who may be later, who's been working on their own in a community and doing, serving the community, but not keeping up on some things.
So you can mold a trainee who may be a little bit less technically sound in the first couple of years by having a really supportive group cases that are appropriate, taking them and continuing because there's. We all, it's practicing medicine. We all, you know, our first year is different than what we're practicing now, I think. So I think some of it is the supportive milieu of a surgical environment that needs to develop that culture and say, okay, here's someone new that we're not going to just put the hardest trauma case on them tomorrow and let them fall. And it's same with other students. So I think your point, mo is also a nuanced point depending on where people move into their practice.
[00:16:49] Speaker B: Thanks.
[00:16:50] Speaker A: Yeah. Well, I would just conclude and thank you both for discussing this. I think, as Brad pointed out, it's a professional responsibility related to our social contract that we are responsible for self governance, both on the the training and education part, as well as continuous monitoring. These are very, very difficult issues and we're all trying to do the best we can, but we have to keep remembering we're responsible to our communities and our society to do what's right for patients.
I found the conversation interesting and would thank you both for sharing your thoughts. And maybe we can delve into this topic again sometime. Again in the future, Mo maybe when the competency based educational movement is a little farther down the road.
[00:17:44] Speaker B: Absolutely.
[00:17:45] Speaker C: Few things for sure. Thank you so much.
[00:17:48] Speaker B: Have a great day.
[00:17:49] Speaker A: Okay.
Cheers.
[00:17:51] Speaker B: Cheers.
